You go to work. You run the calls: the boring, the exciting, the obnoxious, the weird. Occasionally, the terrible. You see, you do, you move on. Like everything else, it runs off our backs. Like rain off a tin roof.

At least, that’s what we tell ourselves. But there’s a secret.

The secret is that hidden beneath the uniformed cowboy swagger of no-problem, we-got-this, no-big-deal, a thick vein of psychological stress is flowing. You don’t see it in your coworkers, because they hide it away. When it reaches you, you do the same, because it’s not okay to show it. Our professional image is unflappability, and you can’t be unflappable if you let things get to you. So we push it under the rug.

Until one of us takes their own life.

PTSD, depression, anxiety, substance abuse, and yes, suicide, are a fact of life in EMS. But we never talked about it. At least, not until a few of our colleagues were brave enough to start shining light upon the problem, in an effort called the Code Green Campaign.

Code Green collects anonymous confessions from our brothers and sisters who can’t speak them out loud, reports the (all too frequent) suicides, collates the research exploring first responder mental health, and performs outreach to build awareness.

Explore their website for more information about their basic mission. After that, come back, because I asked them to unpack a few of the subtleties behind this problem and how they’re trying to solve it.

Question: While most first responders agree with the need for the Code Green Campaign, most of us haven’t actually done anything about it. You did. How and why did it first come about? What was the impetus and how did the early days take shape?

Answer: In March of 2014 one of my co-workers died of suicide. After his death I was talking about it with a group of friends, and we realized that even though we worked for different agencies in different states, we all knew someone that had died of suicide or had a serious attempt. We knew that this couldn’t be a coincidence, so I started looking into it further. I couldn’t find a lot of data, but what I did find told me that this was a much bigger problem than anyone realized.

Once we established that there was, in fact, a mental health problem, as well as a stigma problem, we started discussing what could be done — particularly about the stigma. It occurred to us that if there was one thing first responders like doing, it is sitting around telling stories. We thought that if we could come up with a way for first responders to share the stories of their own mental health problems, other people could read them and realize they weren’t the only ones struggling. We started collecting the stories and posting them on social media every Monday, Wednesday, and Friday. Things blew up from there.

In the early days things moved fast. My co-worker died on March 12th, and on March 16th we came up with the story sharing idea. We came up with our name a couple days later, and I think it was by March 23rd that we had our Facebook page up and running and stories being shared.

Q: Let’s get down to the elephant in the room. Why is this a problem for us? Why do EMS providers seem to be at higher risk for mental health issues in general, and for suicide in particular, compared to bakers, librarians, and schoolteachers?

A: I’m going to preface this answer with the warning that this is a lot of supposition, extrapolation, and educated guesswork. PTSD has most extensively been studied in the military population, so that is the best info we have. This is also a simplified answer, since the long answer would probably beat a doctoral dissertation in length.

We are frequently exposed to known risk factors for PTSD, such as seeing people hurt or dead, feeling helplessness or fear, having poor social support after a traumatic event, and having extra stress outside of work (marital, financial, etc).

We are poorly prepared for the realities of the job. Yes, we’re warned that we’ll see blood and guts and gore, but we’re not told that we are going to feel helpless on a regular basis, or that we’ll be scared we hurt a patient or made them worse. We’re not taught about how different this job can be from normal jobs, and how hard it can be for spouses and other family members to understand what we go through.

Aside from stressful calls, we’re exposed to higher rates of assault, vehicle crashes, and workplace injuries than many fields, which can add to the trauma.

We seem to have higher rates of depression, anxiety, and substance abuse, although it is unclear why.

We work in a very macho field and we’re supposed to be the helpers, not the ones that need help. There have also been reports of people being suspended or fired after admitting they have a problem. That combination helps create a huge stigma against admitting any sort psychological problem and asking for help.

We have more knowledge about lethal means of suicide.

Q: Okay, so let’s contrast EMS against some similar fields. Other first responders like fire and police, or medical personnel like doctors and nurses, all seem share most of the qualities you listed. Are they in the same boat? Or is there anything that puts us at greater risk compared to them?

A: Other first responders like fire and police are in the same boat. In fact, we don’t separate EMS numbers from fire service numbers because the employee base is so entwined. There are almost no fire departments out there who don’t do any EMS at all, so it is tough for us to draw a line as to who counts as EMS and who doesn’t. Just because an agency doesn’t transport doesn’t mean their employees/volunteers aren’t exposed to the same trauma. If you can’t draw the line at transport versus non-transport, where do you draw it? In the long run, it becomes almost impossible to separate people out. With police officers it is easier, but their suicide rate is on par with Fire/EMS. I believe that in 2014 there were over 140 reported police suicides.

As far as other medical professionals go, we do know that doctors do have a high rate of suicide, to the tune of 46 per every 100,000 (for first responders we’re looking at about 30 per 100,000). We don’t know what the suicide rate is for nurses, PAs, or NPs, but we wouldn’t be surprised to learn it is also high.

This is purely supposition on my part, but I do think we are particularly susceptible, because EMS is less developed than other medical fields. Nurses and doctors have well-established professional organizations representing them at the state and national levels. EMS is much more fragmented. The one big difference we’ve especially noticed with nurses and doctors compared to EMS is that many states have license preservation programs in place for RNs and physicians, but not for first responders. That is, if they have a mental health or addiction issue, their state may have an official program in place to help them keep their license while getting help. Few (if any) states have a similar program for first responders. EMS doesn’t have that kind of well-organized advocacy yet.

Q: I expect many of our readers aren’t familiar with license preservation programs. What are they and what are the possible ramifications when we lack one?

A: My answer is based on the states I’ve lived in. From what I understand, most states have such a program set up for either doctors and/or nurses. Basically, the state has recognized that nurses and doctors spend considerable time and money to obtain their licenses, and that it is in everyone’s best interest to keep them on the job, rather than automatically revoking their license. Here is an example of how it would work: say a nurse starts diverting narcotics. She self-reports her behavior to her employer and to her state licensing agency. She will likely be suspended or fired from work, but if the state has a license preservation program her license will only be suspended. The licensing board will then review the case and outline what the nurse has to do to get her license reinstated. They may require her to complete a treatment program, attend weekly counseling sessions, and submit to monthly drug tests. As long as she meets those requirements, she can keep her license.

The issue with lacking a license preservation program is that it creates an atmosphere of fear. People will avoid seeking help for anything they think could possibly cause their license to be suspended, since they have no way of knowing the outcome of that. No license means no job, and unless you want to move to another state, you’d have to come up with a new career fast.

Q: In the absence of such programs, is there a real possibility that EMS providers can lose their jobs or even their certifications merely for reporting mental health issues? In other words, no diversion or actual violations, just the typical paramedic suffering from depression, anxiety, or PTSD?

A: This question is difficult to answer because it is based on the idea that people are routinely reporting their mental health issues to the employer or the state. Unless someone is seeking to use Worker’s Comp or other employment benefits for a mental health issue, there is no reason to be reporting routine treatment to anyone (unless it is required, like with some communicable diseases). Someone wouldn’t report that they’re being treated for asthma or hypertension to their employer or state licensing board, so why would they report depression or PTSD? Employment benefit issues aside, in absence of diversion or actual violation it really doesn’t make sense for anyone but the person and their treatment team to know anything.

Such programs are generally more reactive than proactive, although in the ones I’ve looked at it is strongly encouraged to self-report issues/violations before they are caught by an employer. In fact, at my employer you’re much more protected if you self-report to the EAP than you are if you get caught.

I think that no matter what the reality is, having programs like these make it so that people don’t feel like they are backed into a corner once they develop an issue. We don’t want people feeling like a situation is hopeless, we want them to be able to see there are options.

Q: I imagine that in most cases, “reporting” occurs in the circumstances of a worker’s compensation claim (i.e. asking the employer to pay for mental health services), or perhaps when an employee needs to take time off work.

In the real world, I expect some employers are inclined to be less than supportive about these types of requests. Are they sometimes refused? Are employees sometimes asked to “prove” that their condition is work-related? Is there a legal framework mandating employers to provide these services and accommodations?

A: We answered earlier that Worker’s Comp claims or using other employment benefits are the instances an employer is most likely to learn that someone is having issues. It is difficult to answer a straight “yes” or “no” to any part of this question. No one has sat down and studied how often requests like the above are made, how often they are granted, how often they are refused, and if the response to such a request is affected by the type of employer or the state the employee is located in. We don’t know how often time off requests for mental health conditions are granted or refused, or how often they are granted or refused compared to other time off requests at that same employer. We could come up with anecdotes of both positive and negative outcomes, but there is no data.

What is and what isn’t covered by Worker’s Comp will vary from state to state and employer to employer. We do know that there are states where psychological conditions are not covered for anyone, or are only covered for certain jobs, and the employer has no control over that. It’s not uncommon for Worker’s Comp claims to be investigated no matter what kind of claim it is, so we would not be surprised if people filing a claim related to a psychological issue would be subjected to some questioning. Just ask anyone who has filed Worker’s Comp for a back injury or knee injury. Worker’s Comp tends to be difficult no matter what.

Furthermore, people who have had to take time off for physical injuries will tell you that on top of their injury being investigated and questioned, they likely also had to jump through hoops in order to return to work. Fitness for duty evaluations, physical agility tests, etc. Because of the differences between state laws and agency policies it is very difficult to know if mental health conditions are being treated differently at a significant rate.

As for accommodations, that is even more complicated. Under the Americans With Disabilities Act (ADA) employers are mandated to provide reasonable accommodations for employees that have disabilities. Now, how many first responders do you know that are willing go through that process, and then admit to their employer that they have a disability that needs to be accommodated? Additionally, first responder agencies are in a tough spot when it comes to accommodations because this field is so unpredictable. Agencies can’t ensure that you’ll never run another pediatric cardiac arrest, or never have to respond to a certain address again. If someone has an anxiety attack while responding to a call, or on scene of a call, is taking them out of service going to be considered reasonable? Probably not. Accommodations get very complicated very quickly.

Q: Interesting. So despite these challenges, the problem is clearly an urgent one. What steps can field staff take to prevent and manage mental health issues, whether for themselves or for their colleagues?

A: Resiliency, and building resiliency factors, seems to be a key to helping prevent mental health issues from arising, so everyone should review what resiliency factors they have and work on building upon them. People also need to be able to recognize signs of decline in themselves, such as worsening sleep, increased drinking, and anger issues. For co-workers, the biggest thing is not to be afraid to say something to someone if you think there is a problem. Asking someone, “Are you thinking of suicide?” is not going to put the idea into their head — so if you’re concerned, ask.

Something else that is important is reducing the stigma around mental health in general. Don’t make jokes about “BS psych patients” or complain that psych calls are a waste of time. This contributes to the stigma and makes it harder for people to admit they have their own problem.

Q: What other points do you want do make on this important topic?

A: We need to keep talking about this and keep the conversation going. Changing how mental health is addressed is going to involve changing the culture, which is going to take time and effort.

For people who want to get involved there are several things you can do. Speak up if you hear someone speaking negatively about mental health, whether in the context of our peers or our patients. If you hear about a suicide, please report it to either Code Green or to the Firefighter Behavioral Health Alliance. All reports are confidential and we do not disclose information without permission.

If you know of a first responder–friendly mental health professional in your area, let us know so we can add them to our resource database. It may not seem like much, but this kind of stuff is incredibly helpful to us and to the cause.

Visit the website of the Code Green Campaign to learn more, read personal accounts, and see else what you can do to help.

Why? Aren’t we right? Well, obviously. But less important than being right or wrong is remembering (at least occasionally) that we could be wrong. We are not infallible. Our opinions may be good, but there are others that are reasonable, rational, and defensible. It’s easy to repeat the same thing so many times that we start to believe the opposing perspective is a farcical one held only by fools and madmen. Yet controversial topics don’t remain controversial in the serious circles of medicine (or anywhere else) unless there are good arguments for both sides. You can pick your position, but that doesn’t make it the only one.

Last time we had so much fun that we decided to do it again. This time our entries include…

Ginger Locke — asks… what if video laryngoscopy really is the best first-pass technique for routine endotracheal intubation?

Click around and read some of these great entries. Then applaud our authors for their humility, mental agility, and overall willingness to step back from their personal dogmas and consider the alternatives.

Next time you start to open your mouth, maybe it’ll help you remember that you could be wrong, too.

Now that our review for Academic Emergency Medicine has been published, I wanted to devote a few words to a discussion that didn’t make it into the article.

We spent a lot of time trying to collate what’s known about one specific phenomenon: the blunt trauma patient with an “unstable” acute injury to his spine who suffers sudden neurological deterioration as a result of ordinary physiological movement. The reason we were interested in this event is because, whether or not we admit it, it’s the basis for our current model of prophylactic spinal immobilization. In other words, the reason we place collars, boards, and other devices on patients until they can be “cleared” is because we want to prevent this phenomenon from occurring.

Anybody who reads our review will probably deduce that we’re a little skeptical about this story. The available data is consistent with a clinical entity that is very rare, and when it does occur may be part of the inevitable natural progression of the disease rather than being a movement-provoked (and hence preventable) event.

This fits well with a rational understanding of the pathophysiology. The only mental model that explains the phenomenon of “sudden collapse” would be something like this: the spinal cord is intact, but is surrounded by a vertebral fracture which is both wholly unstable and contains some kind of knife-like bony structure which is poised to transect the cord given the wrong movement. Or perhaps: the bony integrity of the spine is totally lost at some level, and the cord is holding on purely by a few strands of nerve which (like guitar strings breaking) might pop loose with any movement.

These models might make sense to the naive layperson, but any medical professional who understands bones and nerves will have to admit that they’re a little silly. (A more realistic story of unstable spinal injuries, of course, is that disconnected structures compress the spine, causing real but much less dramatic sequela.) Do they never occur? Well, we can’t say that. They are not physical impossibilities, in the sense that they violate a law of thermodynamics or mathematics or grammar. But they are inconsistent with physiology — and in the absence of outcome data, physiological rationale is the only clay we’re working with.

How much room remains on the table for the sudden, irreversible event described in legend? At this point, it’s fair to say there is very little room. We cannot say there is none. There isn’t enough evidence for that. The knee-jerk EBM reaction is to suggest further study, but as Hauswald pointed out in his commentary, that may not be realistic. To make the distinction between “a very rare thing” and “nothing” would require a study of tremendous size, and even then a critic could still ask for more; proving non-existence is a philosophical impossibility.

But as pragmatists, we can say that “very very very rare” and “nonexistent” are clinically indistinguishable. It’s not impossible that beta blockers can cause anaphylactic reactions, that someone being operated upon could slip off the table, or that the hospital could lose power during a course of mechanical ventilation — yet we don’t feel obliged to inform patients about these risks. At some point, scenarios leave the realm of plausible and foreseeable sequelae and enter the territory of “anything’s possible.”

That being established, the question becomes this: if we banish the specter of the boogeyman, what are we left with? Does the entire concept of spinal immobilization become void? Am I an enemy of the board & collar?

No. Here are some alternate models.

The orthopedic model

This places spinal injury on the same level as other orthopedic diseases.

A patient arrives at the ED with a distal radius fracture. What do we do? We examine it clinically, we manage their pain, we obtain appropriate imaging to help guide our care, and — oh yes — we make some effort to immobilize the injury.

Why? Not because we’re afraid of any boogeyman. We aren’t terrified that if the patient lifts his arm and there is some miniscule movement, a hidden razorblade of bone will cut off his arm and render him immobile. Everyone would look at you like you were wearing a silly hat if you suggested that, because it’s a silly thing to say.

Nevertheless, it is probably wise to to make a good-faith effort at limiting movement around the site of injury. Unnecessary manipulation may promote further trauma to muscles, nerves, and vessels, which could induce unnecessary long-term morbidity, prolong recovery, or at least complicate management and increase acute pain.

And maybe that’s how we should view early spinal care. Nothing dramatic. No boogeymen. Just the same logical, unexciting approach that informs our approach to splints, slings, and casts.

You’ll notice that if we fail to apply those devices for five seconds, nobody freaks out, because it’s not that kind of intervention. You’ll also notice we can study their value in controlled studies without anybody gearing up for a lawsuit.

The “correlation is not causation” models

In our paper’s discussion, we briefly mentioned two possibilities that warrant further attention.

We are all supposedly clever people who understand how easily causation can be assigned to unrelated events, yet when a patient moves their neck or back, and shortly afterwards suffers neurological deterioration, we automatically assume that one caused the other. This is called “temporal association,” and while we can’t help but make the connection, it’s wrong as often as it’s right. (See the unfortunate coincidence of “vaccines caused my child’s autism.”)

Other than the cynical explanations of “this association never occurs” (probably wrong) or “it’s purely coincidence” (possible) there are two more sophisticated models worth considering:

The Unmasked Inevitability: An injury exists that would eventually have progressed to a worse neurological status (hours, days, or weeks later). However, the trauma of a movement event induces that deficit to present earlier. The long-term outcome is the same, but the deterioration is now temporally linked with the movement.

The Hidden Aftereffect: Early, unstabilized movement has no immediate effect, but the added insult to the cord promotes edema and other sequelae in the hours/days/weeks that follow. The end result is a poorer long-term outcome that could have been improved by limiting early spinal movement, yet with no obvious association between the two.

Both of these are extremely plausible pathways that we’ve proven to exist in many other diseases. Neither requires the presence of any boogeyman. And since both are completely unrelated to any naive temporal association, either one could only be detected using controlled, outcome-based studies, not this sort of childish anecdote-mongering.

The “forget it, I’m so done” model

Long spine boards may already be on their way out.

EMS services and hospitals around the country are beginning to get aboard the bandwagon of “ditch the backboard in most cases (but keep the collar).” This is very nice. But it’s interesting to examine why it’s happening.

There is no evidence for the benefit of either collars or boards. Any physiological rationale applies equally to both. (Yes, unstable C-spine injuries are somewhat more common than injuries at lower levels, but not so much as to make a difference here.) So why get rid of one but not the other?

It’s because the harms of boards are considered to be greater. There is more evidence that boards cause pain, stasis ulcers, respiratory compromise, and other negatives. However, none of these are major harms, nor are they terribly well demonstrated (most being shown only in small, unreplicated studies where a handful of volunteers were strapped to boards for a few hours). In other words, not exactly a knock-down argument.

If you believe that either device prevents serious morbidity, then these minor risks would not bother you. The only way that the side effects of backboards can be the deciding factor is this: you don’t really think there’s any benefit at all. Some harm + no benefit = out they go.

But remember that on any analysis, the benefits of boards vs. collars are equal zeroes. So once again… why keep one and ditch the other?

The true explanation of the backboard exodus seems to be that everybody finally threw up their hands and said collectively, “I’ve had it with these stupid things.” There was no landmark study or historical turning point. We just saw the writing on the wall.

Since they’re of a kind, the same thing might eventually happen to collars.

Do I think this would be a great idea? No. Because as we’ve discussed in this post, even if we exorcise the boogeyman from our thinking, that doesn’t mean there can’t be any benefit from these devices. It just means the possible benefit becomes more boring and less dramatic, and can now be studied, quantified, and weighed against other factors, rather than being an unassailable matter of dogma. And rather than burning our boards and collars, it means we’re free to recruit them in flexible and useful ways (such as using boards to move patients when it’s the most convenient method, or using collars to stabilize the necks of intubated patients when it’s helpful), rather than invoking them ritualistically.

So what now?

I hope these remarks shine a little light on some possible ways forward. I think many people feel that, if we drop the current model of early spinal care, we’re left with emptiness and nihilism. But really, the current model is based upon a fairytale: if we use our [talisman], we’ll keep away the [boogeyman]. Fairytale-based thinking prevents better understanding, because you can’t study a fairytale. Once we banish that, the entire disease opens up to the kind of rational approach that can stand alongside the rest of our armamentarium, and becomes amenable to the sort of boring explication offered by clinical research.

A person suffers a traumatic injury, usually a minor one, like bumping their head or crunching their fender in traffic. Afterwards, they appear fine, without deficits or any great pain. Ambulance and hospital personnel are unimpressed. But all of a sudden, our seemingly-well patient makes some slight movement — maybe he turns his head — and instantly collapses to the floor, unable to move. He is paralyzed forever, and it’s all because of the unstable spinal injury that you missed.

You heard this cautionary fable in EMT or paramedic class. They tell it in medical school, in the emergency department, and on the trauma wards. It goes back decades. And it makes sense, right? Even a layperson would agree that if the structure of the spine is damaged, the cord it protects will become vulnerable, just like how you’re not supposed to poke the soft spot on a baby’s head.

In fear of this event, we go to great lengths to prevent it. We wrap collars around our patients’ necks, we tie them onto boards, we strap and tape and secure. If their spine can’t protect the cord, by golly we’ll protect it instead, at least until somebody definitively proves that there’s no injury. Which there usually isn’t. But still.

Here’s the trouble: practically nobody has actually seen this phenomenon of mechanical instability occur. For real; the next time somebody mentions it, ask if it’s happened to them. No, they’ll say; but my partner’s cousin’s babysitter saw it a few years back. And if you bother to track that person down, invariably you find that the case either never occurred or has become terribly dramatized through the telling. Steve Whitehead calls it the “Sasquatch event.”

So does this happen at all? After all, many things in medicine that make sense aren’t real. Indeed, doubt has grown lately as to whether our spinal immobilization precautions are effective, and we’ve become more aware of the harms associated with them; as a result, backboards have become increasingly vilified in recent years, and “selective immobilization” algorithms have been accepted in some areas. But there’s been less attention to the question of whether the disease itself is real or a myth, and I wanted to know.

So we went and looked. With the help of four folks smarter than me — Domenic Corey, NREMT-P; James Oswald, B.Emerg Health (Paramedic); Derek Sifford, FP-C; and Brooks Walsh, MD, NREMT-P — we canvassed the literature as far back as possible to dig up any actual, confirmed, peer-reviewed reports of this event. And we just published our findings in the journal Academic Emergency Medicine. Check it out. (And also check out the accompanying editorial by spine connoisseur Mark Hauswald, who you know from “that Malaysia study.”)

I won’t spoil the results, but let me put it this way:

Despite looking across 50+ years, we found few examples.

Most of them weren’t very impressive.

Even fewer occurred in the EMS setting, and none of those were the classic, sudden event you’ve heard about.

So the next time your buddy mentions this unicorn, tell him you don’t doubt him, but that he should write it up for the journals — because it’ll be the first one, and that’s publishable.

This has been an exciting project for another reason. From start to finish, this paper was the child of two parents: the FOAM and EMS communities. Of my four co-authors, I knew three of them exclusively through the web, and have only met two, yet we share interests and passions enough to collaborate on a project that took us over a year. Moreover, every one of us is either an EMT or paramedic, most of us still working actively in the field (although in a few cases we’ve accumulated some other titles too). In fact, had this reached print a few months sooner, the fanciest initials of the lead author would be EMT-B, and that should tickle you.

So never let it be said that the nonsense in this profession is invincible, or that we can’t be the ones to exorcise it. We can fix our own problems, and if we spent more of our energy on moving forward rather than complaining, it just might happen sooner than you think.

The short story is this: within the next few weeks, this site will be moving to the First Arriving blogger network. Hopefully, this process will be relatively seamless and invisible, and you won’t notice anything change. There may be a brief downtime.

The longer version is this: the EMS Blogs network, where we formerly made our home, is shutting its doors. Dave Konig, the network founder and administrator, has made the decision to close up the existing host and relocate the constituent blogs. He can explain better than I can, but things have been a little rocky recently, and astute readers will probably still notice some intermittent outages and broken corners of this site. Hopefully this will all be repaired, or at least repairable, after the move.

The sentimental version is this: the fact that Dave is no longer able to dedicate an unreasonable amount of his free time to serving us authors is not a personal failing on his part. Actually, it’s the opposite. It just highlights how much he’s done for us over the years.

I’ve remarked upon this before, but I believe it’s the folks like Dave in the world who deserve whatever attention we can point their way. They will never ask for it, and if you let them, they’ll remain an invisible part of the backdrop. Yet here are the facts: you would not be reading this blog, nor any of its independent content, nor its sister site Lit Whisperers, if it weren’t for many, many hours of work by Dave. We are not paying him, and he has never made any efforts to monetize the network or profit from us in any significant way. Our names run in the banners, not his. He doesn’t even get a thank you, because mostly we forget he exists.

So now that we’re parting ways, I hope we can all take a moment to remember his efforts.

Dave has done a huge service for the EMS blogging and FOAM community; I am grateful; and you should be too.